Which life‑threatening conditions must be excluded in a patient presenting to the emergency department with acute chest pain?

Life-Threatening Conditions to Exclude in Acute Chest Pain

In the emergency department, six immediately life-threatening conditions must be rapidly excluded in any patient presenting with acute chest pain: acute coronary syndrome (ACS), acute aortic syndromes, pulmonary embolism (PE), tension pneumothorax, esophageal rupture, and pericardial tamponade. 1

Mandatory First 10 Minutes: The Triple Assessment

The initial evaluation focuses on three simultaneous actions that must occur within 10 minutes of arrival:

• Obtain and interpret a 12-lead ECG within 10 minutes to identify ST-segment elevation myocardial infarction (STEMI), ST-depression, T-wave inversions, or other acute ischemic changes 2, 1
• Measure cardiac troponin immediately when ACS is suspected, as this is the most sensitive and specific biomarker for myocardial injury 2, 1, 3
• Assess vital signs and hemodynamic stability including heart rate, blood pressure, respiratory rate, and oxygen saturation 1

The Six Life-Threatening Diagnoses: Clinical Recognition

1. Acute Coronary Syndrome (ACS)

Clinical presentation: Retrosternal pressure, squeezing, or heaviness that builds gradually over minutes (not instantaneously), often radiating to the left arm, neck, or jaw 2, 1

Key associated symptoms: Diaphoresis, dyspnea, nausea, lightheadedness 2, 1

Physical examination findings: May include crackles, S3 gallop, new mitral regurgitation murmur (suggesting papillary muscle dysfunction), or a completely normal examination in uncomplicated cases 1

Critical pitfall: A normal initial ECG does NOT exclude ACS—30-40% of acute myocardial infarctions present with a normal or non-diagnostic ECG 1

2. Acute Aortic Syndromes (Dissection)

Clinical presentation: Sudden-onset severe tearing or ripping chest pain with radiation to the back 2, 1

Physical examination findings:

• Pulse differential between extremities (occurs in ~30% of patients, more common in type A dissections) 1
• Aortic regurgitation murmur (present in 40-75% of type A dissections) 1
• Syncope (occurs in >10% of cases) 1

Diagnostic clue: The combination of severe pain, pulse differential, and widened mediastinum on chest X-ray predicts >80% probability of dissection 1

Imaging required: CT angiography of chest, abdomen, and pelvis; or transesophageal echocardiography if CTA is contraindicated 4

3. Pulmonary Embolism (PE)

Clinical presentation: Sudden-onset dyspnea with pleuritic chest pain that worsens on inspiration 2, 1

Physical examination findings: Tachycardia and dyspnea are observed in >90% of patients 1

ECG findings: Right ventricular strain pattern may be present 1

Imaging required: CT angiography using PE protocol in stable patients with high clinical suspicion 4

4. Tension Pneumothorax

Clinical presentation: Dyspnea and inspiratory chest pain 1

Physical examination findings:

• Unilateral absence of breath sounds 1
• Tracheal deviation 1
• Hypotension 1

Management note: This is a clinical diagnosis requiring immediate needle decompression before imaging confirmation

5. Esophageal Rupture (Boerhaave Syndrome)

Clinical presentation: History of forceful vomiting preceding chest pain 1

Physical examination findings:

• Subcutaneous emphysema 1
• Pneumothorax in ~20% of patients 1
• Unilateral decreased or absent breath sounds 1

6. Pericardial Tamponade

Clinical presentation: Pleuritic chest pain that worsens when lying supine 1

Physical examination findings:

• Pericardial friction rub 1
• Signs of hemodynamic compromise 1
• May be accompanied by fever 1

ECG findings: Diffuse ST-elevation suggests pericarditis 4

High-Risk Physical Examination Findings Requiring Immediate Action

Perform a focused cardiovascular examination looking specifically for these danger signs:

• Hemodynamic instability: Systolic blood pressure <100 mmHg, heart rate >100 bpm, or heart rate <50 bpm 1
• Heart failure signs: Crackles, S3 gallop, elevated jugular venous pressure 1
• New murmurs: Mitral regurgitation (papillary muscle dysfunction) or aortic regurgitation (dissection) 1
• Pulse differential: Assess all four extremities for asymmetry to detect aortic dissection 1
• Unilateral breath sounds: Indicate pneumothorax or massive pleural effusion 1
• Subcutaneous emphysema: Points toward esophageal rupture or pneumomediastinum 1

Serial Troponin Strategy for ACS Exclusion

For high-sensitivity troponin: Repeat measurement 1-3 hours after initial sample 2

For conventional troponin: Repeat measurement 3-6 hours after initial sample 2

Critical timing: Serial troponin measurements must be obtained on arrival and repeated at 6-12 hours from symptom onset, monitoring for rising or falling pattern indicative of acute myocardial injury 4

Single troponin exception: For patients with acute chest pain, normal ECG, and symptoms that began at least 3 hours before ED arrival, a single high-sensitivity troponin concentration below the limit of detection on initial measurement is reasonable to exclude myocardial injury 2

Special Population Considerations

Women

• More frequently describe pain as "tearing" and less often "grinding" 1
• At high risk for underdiagnosis of ACS 1
• Emphasize accompanying symptoms: nausea, fatigue, dyspnea, jaw pain, neck pain, back pain 1

Older Adults (≥75 years)

• May present with atypical symptoms: isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain 1
• ACS must be considered even in the absence of typical chest pain 1

Patients with Diabetes

• More likely to present with vague abdominal symptoms, confusion, or isolated dyspnea 1
• Higher risk for silent ischemia 1

Critical Pitfalls to Avoid

• Never rely on a single normal ECG to exclude ACS when clinical suspicion remains high—perform serial ECGs every 15-30 minutes during the first hour if initial ECG is nondiagnostic 4
• Never discharge based on a single troponin drawn less than 6 hours from symptom onset 4
• Never delay ED transfer from office settings to obtain troponin testing when ACS or other life-threatening causes are suspected 1, 3, 4
• Never interpret nitroglycerin response as diagnostic of cardiac ischemia—esophageal spasm and other conditions may also respond 1, 4
• Never assume young age excludes ACS—it can occur in adolescents without risk factors 1
• Never dismiss sharp, pleuritic pain as excluding ACS—pericarditis and atypical presentations can occur 1

Transport and Pre-Hospital Management

EMS transport is mandatory for any suspected life-threatening condition—personal automobile transport is associated with increased risk and should be avoided 1

Pre-hospital ECG acquisition enables rapid reperfusion therapy if STEMI is identified and reduces mortality 1

Trained EMS personnel can administer arrhythmia treatments, perform defibrillation en route, and provide shorter travel times to the emergency department 1

Imaging Strategy for Uncertain Etiology

The "triple rule-out" CT angiography protocol can simultaneously assess all three major vascular causes (ACS, acute aortic syndromes, and PE) in a single scan for patients with acute chest pain of uncertain etiology 5, 6

Indication: Atypical chest pain with low to intermediate risk, especially in older patients 6

Caution: The increased radiation dose from extended volume coverage must be considered, particularly in younger patients 6